Gmünder ErsatzKasse Research Articles

Distal Forearm Fractures in Children and Adolescents: Frequency and Health Care Provision in Germany

Despite their frequent occurrence, there are no standardized recommendations for treating distal forearm fractures in growing children. Due to the marked remodelling capacity, conservative therapy is the first choice treatment of fractures in children. However, there are concerns that the possibilities of conservative treatments are often underestimated. Information on the health care situation in Germany on this issue is scarce. The present study is based on routine data of a German Health Insurance fund, the Gmünder ErsatzKasse (GEK). Data on diagnoses and treatment of insured persons aged 0-15 years were analysed for the period from 01/07/2005 to 30/06/2009 regarding the frequency of distal forearm fractures and fracture treatment. The overall incidence rate was 56.8 per 10 000 person-years (64.5 in boys; 48.7 in girls). Most of the distal forearm fractures occurred during spring and summer months. The majority of the fractures were immobilized in a plaster cast (84.2%; n=2 609). 8.7% (n=270) of the fractures were treated with closed reduction and percutaneous osteosynthesis. 4.5% (n=138) were treated with closed reduction without any form of osteosynthesis. Only 1.4% (n=43) of the fractures were treated with open reduction. Our study shows that boys suffer distal forearm fractures more frequently than girls and that incidences tend to be higher in older children. In addition, analyses indicated seasonal differences between the age groups. In childhood, distal forearm fractures were treated more often conservatively than operatively. However, it was remarkable that fractures in the case of closed reduction were more frequently fixed with an osteosynthesis than just by immobilization in a plaster cast.

Sex-specific differences in drug utilisation in different phases of life

The aim of the present study is to analyse sex-specific differences in drug utilisation during different phases of life using relevant diseases as examples. We used a cohort of 1.7 million subjects who were insured with the Gmünder ErsatzKasse (GEK), a German health insurance fund, for at least one day in all four quarters of 2009. We analysed subjects with outpatient diagnoses of the following diseases: attention-deficit/hyperactivity disorder (ADHD) (0-17 years), hypothyroidism (18-49 years), osteoporosis (50-79 years) and coronary heart disease (80 + years). Analysis was performed on an active-substance level. A number of differences were observed in drug treatment for the selected diseases (for example, substances for ADHD were prescribed more often in males and for hypothyroidism more often in females), as well as in prescribing practices relating to other drugs used in these groups. However, clear explanations for these differences, such as drug approval status, were not always apparent.

Effekt einer evidenzbasierten Verbraucherinformation zur Entscheidungsfindung beim kolorektalen Screening

Evidence-based information is a prerequisite for informed choice. We compared the effect of evidence-based information on colorectal cancer screening with standard information in a randomised controlled trial. The primary endpoint was informed choice. We randomised 1,577 people insured by a large German statutory health insurance scheme, the Gmünder Ersatzkasse (GEK). The evidence-based information significantly increased informed choices: 44.0% vs. 12.8%; (difference 31.2%, 99% CI 25.7-36.7%; P<0.001).

Did the removal of the indication of nocturnal enuresis for intranasal desmopressin change prescribing practice?

The indication for the treatment of primary nocturnal enuresis was removed from all intranasal preparations of desmopressin in May 2007. Objective of this study was to examine whether and how fast this regulatory decision changed prescribing in affected children. We analyzed claims data of the Gmünder ErsatzKasse (GEK) over the years 2004-2008. All children and adolescents aged 0-18 years who received at least one out-patient diagnosis of urinary incontinence in the corresponding years were included. Our outcome of interest was the proportion of oral desmopressin and its change over time. A total of 6308 to 7207 children with a mean age of about 8 years were included annually (62-63% were male) and 14 746 packages of desmopressin were analysed (49.9% intranasal; 50.1% oral; 0.01% parenteral preparations). The proportion of patients using desmopressin decreased slightly from 13.9% in 2004 to 12.6% in 2008 ( p for trend = 0.0131). Between January 2004 (39.1%) and December 2006 (41.3%), the proportion of oral forms was nearly constant and doubled after that within a few months to about 80%. Immediately after the removal of the indication for intranasal desmopressin, an increased prescribing of tablet forms in affected children was found in Germany.

Regionale Unterschiede in der Nutzung des Aut-idem-Verbots bei Älteren nach Einführung der Rabattverträge

As of 1 April 2007, pharmacists in Germany filling prescriptions covered by the statutory health insurance system (Gesetzliche Krankenversicherung, GKV) are required, whenever possible, to dispense a preparation for which a rebate contract is in effect. The physician can block drug substitution by crossing out 'aut idem' ('or the like') on the prescription form, for which regional variations were found. We have studied the differences between physicians belonging to different regional Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, KVs) in the use of the no-substitution option in the elderly. We used claims data of the Gmünder ErsatzKasse (GEK) and drew a random sample stratified according to the 17 KVs and 3 age groups (65-74; 75-84; 85+ years) of at least 75 continuously insured persons in October 2008 per stratum. After that, all prescriptions in which the physician could potentially have exercised a no-substitution option were selected and all relevant original prescriptions were examined. All estimates were weighted according to KVs, age groups and sex as of the structure of the GKV. The sample comprised of 3 672 persons and 5 745 prescriptions. The percentage of no-substitution prescriptions was 20.1% (95% confidence interval [95% CI] 18.7-21.5) and we found no differences according to age and sex. Considerable differences were seen between the KVs that vary 6.8-fold between 6.2% (95% CI: 3.2-9.2) in Saarland and 42.2% (95% CI: 34.1-50.4) in Saxony. The use of the no-substitution option does not depend on age and sex of the patient but rather depends on regional factors. These considerable regional differences show that, in several regions, the use of the no-substitution regulation influences the effect of rebate contracts.

Versorgungsforschung mit Routinedaten in der Onkologie

Cancer is in the focus of public and scientific interest as one of the leading causes of death, with an increasing case load due to demographic changes and rising treatment costs. Comparatively, little is known about health care utilization of cancer patients. This article first gives an overview of health services research and claims data of German statutory health insurance funds. Second, claims data of the Gmünder ErsatzKasse (GEK) for a period of 3 months (10-12/2008) are used to analyze patterns of drug prescriptions by oncologists. A total of 1.98 million prescriptions were included. Based on all prescriptions, the proportion of compounded prescriptions is about 17 times higher for oncologists compared to other physicians (34.4% vs. 2.0%). Fur- thermore, the costs of these solutions prescribed by oncologists are higher (median: 397.68 Euros vs. 15.45 Euros). Health services research in oncology is urgently needed. Claims data of German health insurance funds offer a broad range of opportunities, especially when linked with other data. However, in the case of individually prepared solutions, claims data provide no further information on the drug.

Umsetzung der Aut-idem-Regelung vor und nach Einführung der Rabattverträge

Due to the aut-idem regulation pharmacies are obligated to substitute medications within the statutory health insurance system to low-priced generics or to dispense the prescribed drug (if only a compound is prescribed low-priced generics have to be dispensed). Since April 1st, 2007 pharmacies have to replace non-rebated by rebated drugs. We aimed to investigate if the prescribing of compounds and substitutions in pharmacies has changed after the introduction of rebate contracts. We used claims data of the Gmünder ErsatzKasse (GEK) and drew 3 random samples of 1,000 relevant prescriptions each in October 2006, 2007 and 2008. After that, all relevant original prescriptions were screened. Between October in 2006, 2007 and 2008, we observed no change in prescribing compounds only (6.0 %; 7.7 %; 6.8 %; p = 0.47). Prescribing compounds was associated with, e. g. dentists, small packages (N1 vs. N3) and antiinfectives. We found a considerable increase in medications that were substituted in pharmacies (2006: 11.3 %; 2007: 29.1 %; 2008: 39.2 %; p <0.0001). Only through the introduction of rebate contracts an increasing amount of substituted medications took place in pharmacies. Before that, the aut-idem regulation had no considerable regulatory effect.

Prescriptions as a proxy for asthma in children: a good choice?

Stock et al. (Eur Respir J 25:47-53, 2005) recently estimated asthma prevalence in Germany using claims data on prescriptions and hospital diagnoses and found high prevalence peaks in infants. Our objective was to critically assess and discuss various aspects of identifying children with asthma using prescription data. We replicated the selection procedure of Stock et al. using data on 290,919 children aged 0-17 years insured in the Gmünder ErsatzKasse (GEK) in 2005. Asthma prevalence was also estimated in a sample of 17,641 children aged 0-17 years participating in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) from 2003 to 2006. In children aged 0-4 years insured in the GEK, prevalences were found to range from 11.7 to 17.7% for boys and from 7.2 to 11.1% for girls when the criteria of Stock et al. were applied. A steady decline in prevalences was observed in older age groups. Asthma prevalence estimated in the KiGGS data showed a quite different distribution. In the age group 0-4 years, prevalences were found to range from 0 to 2.6% in boys and from 0 to 1.0% in girls; in children >4 years, prevalences were found to increase with increasing age. When additional validation studies were taken into account, asthma medications were found to be prescribed not only for asthma but also for other respiratory diseases. In addition, not all children with current asthma had prescriptions. We therefore conclude that asthma medications are therefore not a good proxy for the disease.

Pattern of intravenous bisphosphonate use in outpatient care in Germany

Intravenous bisphosphonate therapy has recently been associated with the development of an osteonecrosis of the jaws (ONJ). If new adverse events have been linked to drugs, basic information on drug exposure in routine care is essential. The aim of this study was to investigate prevalence as well as duration and cumulative doses of intravenous bisphosphonate treatment. We analysed data of the statutory health insurance company Gmünder ErsatzKasse (GEK) over the years 2000-2006. We first estimated treatment prevalence in 2006. We further studied a cohort of new users of intravenous bisphosphonates who initiated treatment between 1 January 2001 and 31 December 2005. We used the Kaplan-Meier method to estimate the time to end of treatment (composite of discontinuation and death). A total of 1024 patients received at least one dose of intravenous bisphosphonates in 2006. The most commonly prescribed agent was zoledronate (53.7%). After standardizing for sex and age, an estimated 0.1% of the German population would have been treated in 2006. Of 1259 new users in 2001-2005, an estimated 40% of men and 22% of women died within 12 months. The median treatment duration was 3.5 months in men and 5.7 months in women. This difference disappears when studying only survivors. Although our study suggests that intravenous bisphosphonates were prescribed mainly for short durations, this result is strongly influenced by the fact that new users had a poor prognosis with a short life expectancy.

Validität forschungsrelevanter Informationen in Arzneimittelroutinedaten von 2000 bis 2006

Claims data of German statutory health insurance companies have been used increasingly over the last years for various research purposes. However, little is known about the validity of these data. Aim of this study was to analyse whether information relevant for research purposes is accurately recorded in computerized out-patient medication claims data. We used data of the Gmünder ErsatzKasse (GEK) over the years 2000 - 2006. A random sample of 300 prescriptions annually was drawn from a total of 6.3 to 7.5 million prescriptions. Data on the scanned original prescriptions ("gold standard") were validated against that information in claims data. Over the years 2000 - 2006 an increasing proportion of dates of writing was recorded accurately (77.3 % to 93.0 %; p for trend < 0.0001). Concomitantly the proportion of handwritten prescriptions declined and that of printed ones increased. Dates of dispensing were barely correct until 2003. Thereafter, the agreement ranged from 65.3 % in 2004 to 86.1 % in 2006 (p for trend < 0.0001). There were significant differences between pharmacy data processing centres (Apothekenrechenzentren). The accuracy of physician and pharmacy identifiers (97,7%, 99,75% and 100.0 %, respectively) was nearly constant over these 7 years. The accuracy of variables analysed in this study is very good for those which are immediately related to the flow of money in German out-patient medication claims data. Recording of dates of prescription and dispensing are fairly good quality.

Wie häufig sind Verordnungs- und Abgabedatum von Arzneimitteln in Routinedaten korrekt erfasst?

Up to now, little research has been done to analyse how often the date of the prescription and the dispensing of the drugs are correct in German statutory health insurance claims data. We used data of the Gmünder ErsatzKasse (GEK). Out of 6.99 million prescriptions in 2005 we drew a simple random sample of 1,000. Dates of filling and dispensing on the scanned original prescription (SOP) were validated against that information in computerized claims data. Factors associated with nonagreement were also evaluated. In 90.4 % (95 % CI: 88.5-92.1) the SOP date of prescribing was identical to the information in the claims data. Compared to printed dates, handwritten or stamped dates were less frequently recorded correctly (95.4 % vs. 40.4 %; p<0.0001). In 76.6 % (95 % CI: 73.8-79.1) of the SOPs the dispensing date was consistent with the information in the claims data. Compared to good legible prints, moderately legible dispensing dates were less frequently recorded correctly (80.4 % vs. 68.2 %; p<0.0001). Because of weak printing about one third of the dispensing dates were moderately legible. In cases where drug exposure has to be measured accurately, original prescriptions should be viewed. There is further need for clarification on the correctness of variables in claims data.